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6.2 Breastfeeding messages

Baby Friendly Step 8

Step 8 of the Ten Steps to Successful Breastfeeding summarizes the basis of breastfeeding management in recognising an infant's total needs. It states:
Encourage breastfeeding on demand.

How often should my baby breastfeed?

Teach parents to recognize and respond promptly to early feeding cues:

  • Early cues
    • wriggling, moving arms or legs
    • rooting, fingers to mouth
  • Mid cues
    • fussing, squeaky noises
    • restless, crying intermittently
  • Late cues
    • full cry, aversive screaming pitch, turns red
Newborn exhibiting a late feeding cue

Newborn exhibiting a late feeding cue


A mother's unique breast capacity and rate of milk synthesis dictates how much milk she has available in the breast at each feed, and infant hunger dictates how much the baby will take at each feed. Neither of these factors are amenable to manipulation.

Kent et al (2006) 1 in their study of 71 thriving, exclusively breastfed babies ranging in age from 1 to 6 months, found:

  • they averaged 11 feeds (range 6 - 18) per 24 hrs.
  • 10 of the babies always fed from both breasts per feed;
  • 19 babies always fed from one breast per feed;
  • the majority of babies sometimes fed from one and sometimes fed from both breasts;
  • 2/3 of babies fed at night, and consumed 20% of their total daily intake at this time.
These researchers concluded that all mothers and babies are unique and mothers should respond to their babies' cues rather than striving to be average.

What should I tell a mother?

Responding to her baby's early feeding cues will ensure baby is fed as often as necessary for her baby.

Is my baby getting enough breastmilk?

Before you can answer this question you need to know how much breastmilk is normal at the various stages of lactation. The average is as follows:1 2 3

Age of baby 24hr volume Infant intake
Approximate conversion: divide millitres by 30 to obtain volume in ounces
Note:
Individual breastmilk intake (and therefore production) does not significantly change from Week 4 to 6 months of age
Day One 37ml (7 - 123ml) few drops - 5ml/feed
Day Two 84ml (44 - 335ml) 5 - 15ml/feed
Day Three 408ml (98 - 775ml) 15 - 30ml/feed
Day Five 705ml (452 - 876ml) depends on feeding frequency, volume available and infant appetite
1 - 6 months 780ml (500 - 1350ml) 30ml - 135ml/feed (6 - 18 feeds/day)

The colostrum received by the baby in the first few days contains highly concentrated immunoglobulins and other protective factors (1.2 Breastmilk Immunology). Also, babies are usually born somewhat 'waterlogged' and therefore a few days of low oral intake assists the infant to clear the excess fluids. The baby is in more need of immunological protection than nutrition in the first few days.

Physiologically the newborn's stomach is not able to hold volumes larger than this. At birth the gastric wall is non-compliant and non-relaxing, which, when combined with the hypomotility of the duodenum, results in early satiety and frequent regurgitation in the first few days.4


Workbook Activity 6.3

Complete Activity 6.3 in your workbook.

In the first 3 days postpartum it can be assumed that the intake is adequate if the baby is positioned well, latches well and suckling actively. After lactogenesis II (average range of clinical onset is 50-73 hrs postpartum 5 ) it is essential that mothers know how to recognize signs that their baby is feeding well.

Teach mothers to:
  • observe the sucking pattern. Baby should be seen to move from a quick suck:suck:suck pattern (a stimulation pattern) to a slower suck:swallow:breathe:suck:swallow:breathe pattern (the nutritive pattern) which is sustained for 2 to 3 minutes. Baby may pause after this and repeat the pattern again. Observation of this pattern confirms milk transfer is occurring.
  • after most feeds the baby will appear satiated
  • baby's mucous membranes will be moist
  • urine and stool output will indicate adequate intake (If it's coming out, it must have gone in!)
Age Urine output Stool output
0 - 24 hours one wet nappy/diaper one or more meconium stools
24 - 48 hours two wet nappies/diapers one or more meconium stools/possible transitional stool
48 - 72 hours three wet nappies/diapers transitional stool
from Day 4 onwards 6 - 8 thoroughly wet nappies/diapers, with clear urine soft, yellow, curdy (at least daily until about 6 weeks)

#1 Rule of infant output - If it's coming out it must have gone in!

It is important for parents to understand this concept. Teach them that the volumes going in as intake will be reflected in output of urine and bowels. Describe the amounts that are displayed in the chart so that parents have a realistic expectation.

Exception: the baby is being given fluids other than breastfeeding

How do mothers receive this information?

Is this information routinely given to ALL mothers? It is critical to the well-being of her baby. If you aren't able to identify when a mother has had this information discussed with her, form a group to develop a protocol to ensure this safeguard is put in place as soon as possible.

Is it the same for bottle-fed babies?

Yes, on the whole it is. All babies should be fed when they cue to feed, and be allowed to finish the feed when they choose to, ie. not forced to finish all the formula or breastmilk in the bottle.
Urine and stool output is also an excellent guide to intake sufficiency for babies fed with a bottle, though those receiving breastmilk substitutes will have a firmer stool and be prone to constipation.

Twins, or more!

Like most mothers, mothers of multiples choose to breastfeed because breastmilk is known to provide better nutrition and health for their babies. Prenatal counseling of mothers of multiples significantly increases the initiation and duration of breastfeeding.6 Attendance at 'mothers of multiples' support group meetings is also associated with increasing the duration of breastfeeding.

Can mothers produce enough milk for multiples?

Yes. The more often and effectively breastmilk is removed from the breast, the more milk will be produced. All mothers should be taught this principle, but it is even more relevant to the mother of multiples.

Studies7 of milk production in mothers of multiples found that the mothers of exclusively breastfed three-month-old twins were producing between 2.2 - 3.4 litres (73 - 113oz.) of breastmilk per 24 hours, while a mother of exclusively breastfed 2½ month old triplets produced 3.08 litres (~103 oz). This compares with studies of breastmilk production for singletons of 750 to 1100 ml (25 - 36oz.) per 24 hours.8

Assisting breastfeeding

There are several issues that should be addressed, namely education about breastfeeding, working with the mother to find the positions that work for her, discussing how she will cope with fatigue and the extra workload, and increasing her food intake to maintain her health.

  • Find an appropriate long couch or bed that provides space on each side of the mother for her to place essentials or place a baby down while she is attending to another baby.
  • Use a firm pillow or foam that will not sink during feeds.
  • The newborn may perform better with breastfeeding if the mother feeds each baby individually during the early learning phase. This allows her the opportunity to bond and learn about each baby's breastfeeding needs and abilities.
  • When breastfeeding two babies at the same time
    • initially the mother will require competent assistance to help with positioning her babies, ensuring correct latch and effectiveness of feedings
    • the mother can first position and attach the baby who requires the most assistance, supporting him with one hand, then assist the more competent baby to attach
    • should one baby have a weaker suck, the milk ejection reflex will be stimulated by the other baby
  • For triplets, two babies can be fed at the same time, then the third baby feeds from both breasts. At subsequent feeds the babies are rotated.
  • Encourage the mother to ask for and accept help from family and friends who have offered assistance so she can concentrate on her task of breastfeeding and caring for the babies, and herself.
Breastfeeding twins

Breastfeeding twins

When should I begin giving baby other foods?

Baby Friendly Point 5

Point 5 of the Seven-Point Plan is concerned with maintaining exclusive breastfeeding until 6 months, and continued breastfeeding with the addition of appropriate complementary foods after 6 months of age.
Encourage exclusive and continued breastfeeding (beyond six months)(to two years), with appropriately timed introduction of (adequate and safe) complementary foods.
The nutrient requirement of well, full term infants is met by exclusive breastfeeding for the first 6 months after birth.

Growth is generally not improved by complementary feeding before six months, even under optimal conditions, i.e., nutritious, microbiologically safe foods. Complementary foods introduced before six months displace the nutritionally superior breastmilk. Replacing even just some breastmilk too soon leads to nutritional deficits and growth faltering, as does not commencing appropriate complementary foods at the appropriate time for his needs. 9

At around 6 months of age, most infant's energy needs for growth and development are beyond the provision of breastmilk alone and appropriate complementary foods will provide additional calories and nutrient for future growth.

Also, developmental milestones also determine that the infant is not functionally ready to take complementary foods earlier than 6 months of age. At, or soon after 6 months, strengthening of the infant's musculature allows him to independently control his head and sit up. The development of fine motor coordination of more distal muscles, including the tongue and lips and their function of bringing in and manipulating more solid food in preparation for swallowing, is indicative of his ability to handle these foods at this age. 9

Between 6 and 24 months of age is a critical time for promotion of optimal growth, health and behavioral development with longitudinal studies demonstrating this is the peak age for growth faltering, deficiencies of certain micronutrients, and common childhood illnesses.

The World Health Organisation 10 recommends the following guiding principles for appropriate complementary feeding to ensure nutritional wellbeing continues once complementary feeding begins:

  • continue frequent, on demand breastfeeding until two years old or beyond;
  • practise responsive feeding (e.g. feed infants directly and assist older children. Feed slowly and patiently, encourage them to eat but do not force them, talk to the child and maintain eye contact);
  • practise good hygiene and proper food handling;
  • start at six months with small amounts of foods and increase gradually as the child gets older;
  • gradually increase food consistency and variety;
  • increase the number of times that the child is fed, 2-3 meals per day for infants 6-8 months of age, and 3-4 meals per day for infants 9-23 months of age, with 1-2 additional snacks as required;
  • feed a variety of nutrient rich foods;
  • use fortified complementary foods or vitamin-mineral supplements, as needed; and
  • increase fluid intake during illness, including more breastfeeding, and offer soft, favourite foods.

  • Eat daily:
    • Meat, poultry, fish or eggs
    • Vitamin A-rich fruits and vegetables
    • Adequate fat content

    A well-planned vegetarian diet that incorporates all macro- and micro-nutrients would be suitable. 11

    Avoid giving drinks with low nutrient value, such as tea, coffee and sugary drinks. Limit the amount of juice offered to avoid displacing more nutrient-rich breastmilk.

    Age Texture Frequency Amount each meal
    Adapted from: WHO 2005
    From 6 months soft porridge, well mashed vegetables, fruit, meats 2 times/day + frequent breastfeeds 2 - 3 tablespoonfuls
    7 - 8 months mashed foods 3 times/day + frequent breastfeeds Increase gradually to 2/3 of a 250ml cup each meal
    9 - 11 months finely chopped or mashed foods & foods baby can pick up 3 meals + 1 snack between meals + breastfeeds 3/4 of 250ml cup or bowl
    12 - 24 months Family foods, mashed if necessary 3 meals + 2 snacks + continued breastfeeding A full 250ml cup or bowl

Baby-led or mother-led eating?

Developed countries approach to complementary foods tends to be in a structured fashion of food preparation (puree or mash), mother-directed using a spoon.
This is not possible or practical in traditional cultures - the infant is directly involved in food time with the family.

Finger foods can be offered to babies so that they can choose their own intake according to ability and needs. This is called Baby-led weaning. A recent study12 showed significantly low levels of food restriction, no association with weight and reported to possibly have a positive effect on later eating habits and weight.

When should I wean my baby from the breast?

Breastfeeding and breastmilk continues to provide protection and growth factors as well as being a quality food source for as long as the child is breastfed. There is no stage of lactation where breastmilk stops having these beneficial effects.

The introduction of complementary foods from 6 months of age is the beginning of the weaning process. The weaning process can take as long as the mother and baby want it to take. The American Academy of Pediatrics recommends breastfeeding continue for at least the first 12 months of life and beyond with the addition of appropriate complementary foods from 6 months.13 The World Health Organisation recommends babies continue to receive breastmilk until at least their second birthday and beyond, with the addition of appropriate complementary foods from 6 months of age.

Despite this knowledge, the number of babies who are being exclusively breastfed at 6 months of age, and the number of babies receiving any breastmilk at 12 months of age is much less than it should be in most countries.

Weaning too early

Have you thought about how you could influence mothers in your area?

Brainstorm some ideas with your colleagues and implement them. Examples could be a poster that simply states “Breastmilk only to 6 months; Breastmilk plus family foods to 2+ years.” Sometimes a simple statement such as that is all the mother needs to know. However, you could also address education about artificial feeding and talk to mothers about the barriers they may see to continuing to provide breastmilk.

What should I remember?

  • The infant feeding cues.
  • The variation in milk production and infant intake in the first 5 days.
  • The expected infant output which indicates adequate intake.
  • How to teach mothers to recognise milk transfer.
  • Expectations for mothers about the frequency of breastfeeding.

Self-test quiz

Notes

  1. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
  2. # Riordan J (2005) Breastfeeding and Human Lactation
  3. # Saint L et al. (1984) The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum
  4. # Zangen S et al. (2001) Rapid maturation of gastric relaxation in newborn infants
  5. # Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview
  6. # Friedman S et al. (2004) The effect of prenatal consultation with a neonatologist on human milk feeding in preterm infants.
  7. # Saint L et al. (1986) Yield and nutrient content of milk in eight women breast-feeding twins and one-woman breast-feeding triplet.
  8. # Kent JC et al. (2004) Frequency, volume and fat content of breastfeeds of exclusively breastfed babies
  9. # World Health Organization (2001) Report of the expert consultation of the optimal duration of exclusive breastfeeding
  10. # World Health Organisation (2010) Infant and young child feeding - Fact sheet N,.342
  11. # Amit M (2010) Vegetarian diets in children and adolescents.
  12. # Brown A et al. (2010) Maternal Control of Child Feeding During the Weaning Period: Differences Between Mothers Following a Baby-led or Standard Weaning Approach.
  13. # AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk